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Abstract [en]

Objective: To evaluate among stakeholders the support for the new, dynamic concept of health, as published in 2011: 'Health as the ability to adapt and to self-manage', and to elaborate perceived indicators of health in order to make the concept measurable. Design: A mixed methods study: a qualitative first step with interviews and focus groups, followed by a quantitative survey. Participants: Representatives of seven healthcare stakeholder domains, for example, healthcare providers, patients with a chronic condition and policymakers. The qualitative study involved 140 stakeholders; the survey 1938 participants. Results: The new concept was appreciated, as it addresses people as more than their illness and focuses on strengths rather than weaknesses. Caution is needed as the concept requires substantial personal input of which not everyone is capable. The qualitative study identified 556 health indicators, categorised into six dimensions: bodily functions, mental functions and perception, spiritual/existential dimension, quality of life, social and societal participation, and daily functioning, with 32 underlying aspects. The quantitative study showed all stakeholder groups considering bodily functions to represent health, whereas for other dimensions there were significant differences between groups. Patients considered all six dimensions almost equally important, thus preferring a broad concept of health, whereas physicians assessed health more narrowly and biomedically. In the qualitative study, 78% of respondents considered their health indicators to represent the concept. Conclusions: To prevent confusion with health as 'absence of disease', we propose the use of the term 'positive health' for the broad perception of health with six dimensions, as preferred by patients. This broad perception deserves attention by healthcare providers as it may support shared decision-making in medical practice. For policymakers, the broad perception of 'positive health' is valuable as it bridges the gap between healthcare and the social domain, and by that it may demedicalise societal problems.

van Vliet, Marja

Abstract [en]

Integrative Medicine (IM) is a care approach that focuses on the overall well-being and healing process of patients rather than solely on their disease. IM educates and empowers people to be active players in their own care, emphasizes the therapeutic relationship, and makes use of all appropriate evidence-based approaches. The health-oriented foundations of IM are in line with the recently posed concept that describes health as ”the ability to adapt and to self-manage”. Due to the shared underpinnings of both IM and the new concept of health, incorporation of this new concept of health may serve as a facilitator for the development and implementation of IM. From a practical viewpoint, working from an integrative care approach requires specific competences from healthcare providers, such as socio-communicative and self-reflective skills, and reflexivity towards a holistic perspective on health. Previous studies have shown that a Mind-Body Medicine (MBM) course can potentially foster these competences among future healthcare providers. This thesis intended to gain increased insight into the prerequisites and tools for implementation of IM. Therefore, in the first part it aimed to explore the attitudes and practice of IM among Dutch nurses and the support for the new dynamic concept of health as ”the ability to adapt and to self-manage” among main stakeholders within the Dutch healthcare community. Furthermore, in the second part it aimed to evaluate the possibilities of an MBM course among medical and nursing students as a tool to foster an integrative care approach.

Methods Both quantitative and qualitative research designs were used. Attitudes and practice of IM were assessed in a semi-structured survey study among 355 Dutch nurses (study I). Support for the new concept of health was explored in a mixed method study, where in the first step data from interviews and focus-groups among 140 stakeholders were investigated by use of manifest content analysis, and in the second step a cross-sectional survey was performed among 1938 stakeholders to verify the findings of the first step (study II). The MBM course was evaluated by a controlled, quasi-experimental intervention study (74 participants / 61 controls among medical students and 47 participants / 64 controls among nursing students) in which validated questionnaires were used (study III). Furthermore, in-depth interviews with 11 medical and 15 nursing students were employed and analysed by a Phenomenological Hermeneutical method to obtain an in-depth understanding of the meaning of the MBM course for the participants (study IV).

Findings Study I showed an overall positive attitude towards IM among nurses. Patient-centeredness and a focus on individuals’ own resources and responsibility to promote health met the most support among both nurses and other stakeholders. These elements were considered to be the main positive aspects of the new dynamic concept of health among stakeholders as well (study II). Use of evidence-based and safe complementary therapies and a healing environment received some support from the nurses, but lack of knowledge and lack of evidence seems to hinder further incorporation in the current healthcare practice (study I). Additionally, study II revealed that health was perceived to comprise six dimensions: bodily functions, mental functions & perception, spiritual / existential dimension, quality of life, social and societal participation and daily functioning. In line with patients, nurses had a more broad conception of health in comparison to other healthcare professionals. Study III showed long-term beneficial effects of the MBM course on two dimensions of empathy (personal distress and empathic concern) among medical students, and on perceived stress and empathy (personal distress) among nursing students. Study IV brought forth that the MBM course can be understood as a pathway to inner awareness and a support to connecting with others as well as the outside world. The following themes were identified: “ability to be more present”, “an increased perception and awareness of self”, and “connecting on a deeper level with others”.

Conclusion It can be concluded from the results in the first explorative part of this thesis that the observed positive attitudes and perceptions among healthcare professionals toward IM and the newly proposed health concept can serve as important facilitators for further implementation of IM within the Dutch healthcare system. Furthermore, the increased ability to deal with stress, improved empathic abilities and more openness toward different perspectives on health and new treatment options among medical and nursing students following a MBM course, as reported in the second part of this thesis, suggest that this course might be a suitable tool to foster an integrative care approach among future healthcare professionals.